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BIG PHYSICS, BIG QUESTIONS –

Extreme therapy: Inside a hospital for dangerous minds

By Helen Thomson

Extreme psychotherapy

(Image: Neil Hall/Rex Features)

THE imposing buildings before me house hundreds of people with some of the most severe mental disorders in the world. Their conditions have led them to commit violent crimes including murder, cannibalism and sexual offences. Now, on the eve of its 150th anniversary on 6 June, I’ve been allowed inside Broadmoor high-security psychiatric hospital. I will get to see how close they are to finding the biological mechanisms underlying extreme types of criminal behaviour.

The 210 patients at Broadmoor, near Bracknell, UK, have schizophrenia, severe personality disorder, or both. They are exposed to many treatments – some developed in the hospital’s own research centre. It is one of these novel weekly therapy sessions that I’m joining today.

Mentalisation-based treatment aims to improve people’s ability to understand their own, and others’, mental states. It has proved successful in decreasing violent behaviour in people with antisocial personality disorder, but this is the first time it has been replicated in a criminal population in a high-security setting. Four patients enter the room. I feel a little on edge; each man is a murderer with a severe mental illness. But each one calmly introduces himself to me – one offering me coffee.

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Although the bars on the windows and security escorts are reminiscent of a prison, the room we are in is large, light and airy. The residents say they prefer Broadmoor to prison. One person recollects that he felt punished by prison wardens – which is why he stole a screwdriver and chased a warden down to stab him. He recounts the story without any trace of emotion. It’s a powerful reminder of the extreme mental illnesses that afflict the people here.

Forensic psychotherapist Martin Humphrey says that preliminary results from the group therapy are promising (Advances in Psychiatric Treatment, doi.org/msj). “Their capacity to coherently knit things in time to talk about how their actions led to what they did has significantly improved,” he says.

Later, I am taken to Broadmoor’s dedicated research suite. The team there is working on identifying what makes a tiny percentage of severely mentally ill people commit a violent crime. They are investigating the potential for using physiological and neurological measurements to predict which patients will respond to which treatments, and as a way of objectively monitoring improvements. “Assessing the risk of reoffending is not an exact science,” says forensic psychiatrist Mrigendra Das. “There’s no blood test for schizophrenia.”

In unpublished results, Das, Veena Kumari from the Institute of Psychiatry at Kings College London and their colleagues used fMRI to scan Broadmoor patients with violent schizophrenia, or violent personality disorder, while showing them faces expressing negative emotions such as anger or fear, and compared the brain activity with that of people who have non-violent schizophrenia.

Violent patients had reduced activation of their amygdala – an area of the brain crucial for deciphering emotions – and the lower the level of activation, the greater the history of violence in the individual. Das suggests that not being able to recognise negative emotions may decrease the inhibition that normally prevents people being violent.

The team will use this information to develop better treatments, such as therapy to increase understanding of emotions, but they will have to be careful. In other unpublished results, Das’s team has found that Broadmoor patients with a history of being abused or neglected actually had higher levels of activation in brain areas associated with interpreting emotions than healthy individuals. “It would appear that these men are overly sensitive to negative emotions,” says Das.

Both of these findings, the first of their kind, could help his team tailor therapy for people, depending on the brain structures that underlie their specific illness.

“Brain imaging could be an extremely useful tool to help develop treatments that are tailored to an individual’s particular deficits,” says Mike Koenigs at the University of Wisconsin in Madison, who has used MRI in US prison facilities to study psychopathic offenders.

Brain imaging could be useful to help develop treatments tailored to particular deficits

In September, Broadmoor researchers will have use of their own fMRI scanner, making it easier to scan people. “We hope to select groups of patients and monitor several brain functions at regular intervals as they progress through different treatment paradigms,” says Das. He hopes that eventually these kinds of scans will provide objective measures of improvement. These could be presented to the UK Ministry of Justice, which ultimately decides whether patients are well enough to leave hospital. Indeed, recent evidence suggests that brain scans can be used to improve predictions of whether people will reoffend (PNAS, doi.org/ms5).

There is fierce debate over whether people with a history of violence can use brain scans as evidence in court (see “It wasn’t me, it was my brain“). The neurophysiological evidence of what makes someone commit a crime is not yet good enough for this, says Das. The current aim, he says, is to shape the care of people with mental disorders. “Ultimately we want to help them resume a life hopefully outside secure services.”

It wasn’t me, it was my brain

Brain scans cannot yet be routinely used to assess how dangerous a person is or to reach a legal decision on responsibility for a crime, says Wolf Singer at the Max Planck Institute for Brain Research in Frankfurt, Germany.

However, research at Broadmoor high-security psychiatric hospital near Bracknell, UK, might change that. Their work looking for objective signals that tell you something about the progress of a therapy, and maybe even a cause of a disorder, is very interesting, Singer says.

It is important to improve our assessment of the “abnormal brain”, says Singer. “If someone who is violent turns out to have a brain tumour he is not exposed to legal measures, but treated as a patient.”

A famous example involved a man who developed paedophilic urges and was arrested. A brain scan (see left) revealed that a large tumour had displaced his right orbitofrontal lobe. Removal of the tumour diminished his symptoms and seven months later he was deemed no risk to the public and returned home. Later, his urges resurfaced. Another scan showed that the tumour had returned. When it was removed his symptoms once again resolved (JAMA Neurology, doi.org/dq8rt7).

Such clear-cut cases of biology causing abnormal behaviour are rare. Generally, Singer says, it is extremely difficult to come up with a robust method of saying whether a person is responsible for their actions. But he adds&colon; “With the refinement of neurological methods these kinds of cases will probably become more frequent.”

Correction&colon;When this article was first published on 12 June 2013, Wolf Singer’s name was misspelled

This article appeared in print under the headline “From asylum to house of healing”